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Network PlatinumPremier Pharmacy (PPO) offered by Network Health Insurance Corporation

Annual Notice of Changes for 2020

You are currently enrolled as a member of Network PlatinumPremier Pharmacy. Next year, there will be some changes to the plan’s costs and benefits. This booklet tells about the changes.

You have from October 15 until December 7 to make changes to your Medicare coverage fornext year.

What to do now

1. ASK: Which changes apply to you

Check the changes to our benefits and costs to see if they affect you.

It’s important to review your coverage now to make sure it will meet your needs next year.

Do the changes affect the services you use?

Look in Sections 1.1 and 1.5 for information about benefit and cost changes for our plan.

Check the changes in the booklet to our prescription drug coverage to see if they affect you.

Will your drugs be covered?

Are your drugs in a different tier, with different cost sharing?

Do any of your drugs have new restrictions, such as needing approval from us before you fill yourprescription?

Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy?

Review the 2020 Drug List and look in Section 1.6 for information about changes to our drugcoverage.

Your drug costs may have risen since last year. Talk to your doctor about lower cost alternatives thatmay be available for you; this may save you in annual out-of-pocket costs throughout the year. Toget additional information on drug prices visit https://go.medicare.gov/drugprices. These dashboardshighlight which manufacturers have been increasing their prices and also show other year-to-yeardrug price information. Keep in mind that your plan benefits will determine exactly how much yourown drug costs may change.

ANOC_2020_H5215_005R20_M OMB Approval 0938-1051 (Expires: December 31, 2021) Accepted 08212019 2620-01b-0819

https://go.medicare.gov/drugprices

Check to see if your doctors and other providers will be in our network next year.

Are your doctors, including specialists you see regularly, in our network?

What about the hospitals or other providers you use?

Look in Section 1.3 for information about our Provider Directory.

Think about your overall health care costs.

How much will you spend out-of-pocket for the services and prescription drugs you use regularly?

How much will you spend on your premium and deductibles?

How do your total plan costs compare to other Medicare coverage options?

Think about whether you are happy with our plan.

2. COMPARE: Learn about other plan choices

Check coverage and costs of plans in your area.

Use the personalized search feature on the Medicare Plan Finder at https://www.medicare.gov website. Click “Find health & drug plans.”

Review the list in the back of your Medicare & You handbook.

Look in Section 3.2 to learn more about your choices.

Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.

3. CHOOSE: Decide whether you want to change your plan

If you want to keep Network PlatinumPremier Pharmacy, you don’t need to do anything. You will stay in Network PlatinumPremier Pharmacy.

To change to a different plan that may better meet your needs, you can switch plans between October 15 and December 7.

4. ENROLL: To change plans, join a plan between October 15 and December 7, 2019

If you don’t join another plan by December 7, 2019, you will stay in Network PlatinumPremier Pharmacy.

If you join another plan by December 7, 2019, your new coverage will start on January 1, 2020.

https://www.medicare.gov

Additional Resources

Customer service has free language interpreter services available for non-English speakers (phone numbers are in Section 7.1 of this booklet).

This information is available for free in other formats. For more information, please contact customer service at 800-378-5234, Monday through Friday, 8 a.m. to 8 p.m. TTY users should call 800-947-3529, if you need information in another format. From October 1, 2019 through March 31, 2020, we are available every day; from 8 a.m. to 8 p.m.

Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at https://www.irs.gov/Affordable-CareAct/Individuals-and-Families for more information.

About Network PlatinumPremier Pharmacy

Network Health Medicare Advantage Plans include MSA, PPO and HMO plans with a Medicare contract. Enrollment in Network Health Medicare Advantage Plans depends on contract renewal.

When this booklet says “we,” “us,” or “our,” it means Network Health Insurance Corporation. When it says “plan” or “our plan,” it means Network PlatinumPremier Pharmacy.

https://www.irs.gov/affordable-care-act/individuals-and-families

https://www.irs.gov/affordable-care-act/individuals-and-families

1 Network PlatinumPremier Pharmacy Annual Notice of Changes for 2020

Summary of Important Costs for 2020

The table below compares the 2019 costs and 2020 costs for Network PlatinumPremier Pharmacy in several important areas. Please note this is only a summary of changes. A copy of the Evidence of Coverage is located on our website at networkhealth.com/medicare/plan-materials. You may also call customer service to ask us to mail you an Evidence of Coverage.

Cost 2019 (this year) 2020 (next year)

Monthly plan premium*

* Your premium may be higher orlower than this amount. See Section1.1 for details.

$295 $296

Maximum out-of-pocket amounts

This is the most you will pay out-of-pocket for your covered Part A and Part B services. (See Section 1.2 for details.)

From in-network providers: $3,400

From in-network and out-of-network providers combined: $3,400

From in-network providers: $3,400

From in-network and out-of-network providers combined: $3,400

Doctor office visits In-Network

Primary care visits: $10 per visit

Specialist visits: $20 per visit

Out-of-Network



In-Network



Out-of-Network



https://networkhealth.com/medicare/plan-materials



Inpatient hospital care

Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.

In-Network

$75 copay per day for days 1-5 of a Medicare covered stay in a hospital.

$0 copay for days 6 and beyond of a Medicare covered stay in a hospital.

Additional days covered.

Out-of-Network

$75 copay per day for days 1-5 of a Medicare covered stay in a hospital.

$0 copay for days 6 and beyond of a Medicare covered stay in a hospital.


In-Network

$75 copay per day for days 1-5 of a Medicare covered inpatient hospital stay, for each admission.

$0 copay per day for all other days of a Medicare covered stay in a hospital, for each admission.

Out-of-Network

$75 copay per day for days 1-5 of a Medicare covered inpatient hospital stay, for each admission.

$0 copay per day for all other days of a Medicare covered stay in a hospital, for each admission.

Part D prescription drug coverage

(See Section 1.6 for details.)

Deductible: $260

Deductible applies to Tiers 3, 4 and 5

Copayment/Coinsurance as applicable during the Initial Coverage Stage:

Drug Tier 1: $2 at a preferred pharmacy and $4 at a standard pharmacy.




Drug Tier 5: 28% at both preferred and standard pharmacies.

Deductible: $260

Deductible applies to Tiers 4 and 5

Copayment/Coinsurance as applicable during the Initial Coverage Stage:





Drug Tier 5: 28% at both preferred and standard pharmacies.


Annual Notice of Changes for 2020 Table of Contents

Summary of Important Costs for 2020 ........................................................................................ 1

SECTION 1 Changes to Benefits and Costs for Next Year................................................... 4

Section 1.1 – Changes to the Monthly Premium ........................................................................................ 4

Section 1.2 – Changes to Your Maximum Out-of-Pocket Amounts .......................................................... 4

Section 1.3 – Changes to the Provider Network......................................................................................... 5

Section 1.4 – Changes to the Pharmacy Network ....................................................................................... 6

Section 1.5 – Changes to Benefits and Costs for Medical Services ........................................................... 6

Section 1.6 – Changes to Part D Prescription Drug Coverage ................................................................... 9

SECTION 2 Administrative Changes ................................................................................... 13

SECTION 3 Deciding Which Plan to Choose ....................................................................... 13

Section 3.1 – If you want to stay in Network PlatinumPremier Pharmacy .............................................. 13

Section 3.2 – If you want to change plans ................................................................................................ 13

SECTION 4 Deadline for Changing Plans ............................................................................ 14

SECTION 5 Programs That Offer Free Counseling about Medicare .................................. 15

SECTION 6 Programs That Help Pay for Prescription Drugs ............................................ 15

SECTION 7 Questions? ......................................................................................................... 16

Section 7.1 – Getting Help from Network PlatinumPremier Pharmacy .................................................. 16

Section 7.2 – Getting Help from Medicare ............................................................................................... 16


SECTION 1 Changes to Benefits and Costs for Next Year

Section 1.1 – Changes to the Monthly Premium


Monthly premium

(You must also continue to pay your Medicare Part B premium.)

$295 $296

Dental Optional Supplemental Benefit premium

$35 $37

Your monthly plan premium will be more if you are required to pay a lifetime Part D late enrollment penalty for going without other drug coverage that is at least as good as Medicare drug coverage (also referred to as “creditable coverage”) for 63 days or more.

If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage.

Your monthly premium will be less if you are receiving “Extra Help” with your prescription drug costs.

Section 1.2 – Changes to Your Maximum Out-of-Pocket Amounts

To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket” during the year. These limits are called the “maximum out-of-pocket amounts.” Once you reach this amount, you generally pay nothing for covered Part A and Part B services for the rest of the year.



In-network maximum out-of-pocket amount

Your costs for covered medical services (such as copays) from in-network providers count toward your in-network maximum out-of-pocket amount. Your plan premium and your costs for prescription drugs do not count toward your maximum out-ofpocket amount.

$3,400

Once you have paid $3,400 out-of-pocket for covered Part A and Part B services from in-network providers, you will pay nothing for your covered Part A and Part B services from in-network providers for the rest of the calendar year.

No change

Combined maximum out-of-pocket amount

Your costs for covered medical services (such as copays) from in-network and out-of-network providers count toward your combined maximum out-of-pocket amount. Your plan premium does not count toward your maximum out-of-pocket amount.

$3,400

Once you have paid $3,400 out-of-pocket for covered Part A and Part B services from in-network providers, you will pay nothing for your covered Part A and Part B services from in-network or out-ofnetwork providers for the rest of the calendar year.

No change

Section 1.3 – Changes to the Provider Network

There are changes to our network of providers for next year. An updated Provider Directory is located on our website at networkhealth.com/medicare/plan-materials. You may also call customer service for updated provider information or to ask us to mail you a Provider Directory. Please review the 2020 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.

It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan, but if your doctor or specialist does leave your plan you have certain rights and protections summarized below:

Even though our network of providers may change during the year, we must furnish you withuninterrupted access to qualified doctors and specialists.

We will make a good faith effort to provide you with at least 30 days’ notice that your provider isleaving our plan so that you have time to select a new provider.



We will assist you in selecting a new qualified provider to continue managing your health care needs.

If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.

If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision.

If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider and managing your care.

Section 1.4 – Changes to the Pharmacy Network

Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our in-network pharmacies. Our network includes pharmacies with preferred cost-sharing, which may offer you lower cost-sharing than the standard cost-sharing offered by other in-network pharmacies for some drugs.

There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our website at networkhealth.com/medicare/plan-materials. You may also call customer service for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2020 Pharmacy Directory to see which pharmacies are in our network.

Section 1.5 – Changes to Benefits and Costs for Medical Services

We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2020 Evidence of Coverage. A copy of the Evidence of Coverage is located on our website at networkhealth.com/medicare/plan-materials.


Dental services – additional benefits

Out-of-Network

You pay 100% of the total cost for non-Medicare covered preventive dental services.

Out-of-Network

Reimbursement up to a maximum of $100 for one non-Medicare covered oral exam and cleaning.





Emergency care In-Network

You pay 25% of the total cost for each non-Medicare covered Emergency room visit outside of the U.S. and its territories.

Out-of-Network


In-Network

$90 per incident for each non-Medicare covered emergency room visit outside of the United States and its territories.

Out-of-Network


Inpatient hospital care

In-Network

You pay a $75 copay per day for days 1-5 of a Medicare covered stay in a hospital.

You pay a $0 copay for days 6 and beyond of a Medicare covered stay in a hospital.


Out-of-Network

You pay a $75 copay per day for days 1-5 of a Medicare covered stay in a hospital.

You pay a $0 copay for days 6 and beyond of a Medicare covered stay in a hospital.


Per Admission you pay

In-Network

You pay a $75 copay per day for days 1-5 of a Medicare covered inpatient hospital stay.

You pay a $0 copay per day for all other days of a Medicare covered stay in a hospital.

Out-of-Network

You pay a $75 copay per day for days 1-5 of a Medicare covered inpatient hospital stay.

You pay a $0 copay per day for all other days of a Medicare covered stay in a hospital.



Inpatient mental health care

In-Network

You pay a $0 copay per day for days 1190 of a Medicare covered inpatient psychiatric stay including lifetime reserve days.

Lifetime reserve days may only be used once.

Out-of-Network

You pay a $0 copay per day for days 1190 of a Medicare covered inpatient psychiatric stay including lifetime reserve days.

Lifetime reserve days can only be used once.


In-Network

You pay a $0 copay per day for days 190 for Medicare covered inpatient psychiatric stay, for each admission, including lifetime reserve days.

Lifetime reserve days may only be used once.

Out-of-Network

You pay a $0 copay per day for days 190 for Medicare covered inpatient psychiatric stay, for each admission, including lifetime reserve days.

Lifetime reserve days can only be used once.

Opioid treatment program services

Opioid treatment program services are not covered.

In-Network

You pay a $0 copay for each Medicare covered opioid treatment program service.

Out-of-Network

You pay a $0 copay for each Medicare covered opioid treatment program service.



Skilled nursing facility (SNF) care

In-Network

You pay a $0 copay per day, days 1100 for a Medicare covered skilled nursing facility stay.

Out-of-Network

You pay a $0 copay per day, days 1100 for a Medicare covered skilled nursing facility stay.

Plan covers up to 100 days each benefit period.


In-Network

You pay a $0 copay per day, days 1100 for Medicare covered skilled nursing facility stay.

Out-of-Network

You pay a $0 copay per day, days 1100 for Medicare covered skilled nursing facility stay.

You are covered for up to 100 days per admission.

Urgently needed services

In-Network


Out-of-Network


In-Network


Out-of-Network


Vision care – additional benefits

Out-of-Network

Reimbursement of up to a maximum of $30 for each non-Medicare covered routine eye exam.

Out-of-Network

Reimbursement of up to a maximum of $40 for each non-Medicare covered routine eye exam.

Section 1.6 – Changes to Part D Prescription Drug Coverage

Changes to Our Drug List

Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is provided electronically. You can get the complete Drug List by calling customer service (see the back cover) or visiting our website (networkhealth.com/medicare/plan-materials).



We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions.

If you are affected by a change in drug coverage, you can:

Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug.

o To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call customer service.

Work with your doctor (or other prescriber) to find a different drug that we cover. You can call customer service to ask for a list of covered drugs that treat the same medical condition.

In some situations, we are required to cover a temporary supply of a non-formulary drug in the first 90 days of the plan year or the first 90 days of membership to avoid a gap in therapy. (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.

If you are a member of our plan and receive a tiering exception or a formulary exception for a drug not on our Drug List, the drug will remain covered under the exception through the end of the calendar year. You will need to submit a new request next year if you wish to continue receiving the drug under an exception.

If you are a member of our plan and receive a formulary exception to remove a restriction on coverage for a drug, the drug will remain covered based on the original expiration date of the exception. The exception may expire before the end of the year or may carry over into next year. You will need to submit a new request when the original exception expires if you wish to continue receiving the drug under an exception.

Most of the changes in the Drug List are new for the beginning of each year. However, during the year, we might make other changes that are allowed by Medicare rules.

When we make these changes to the Drug List during the year, you can still work with your doctor (or other prescriber) and ask us to make an exception to cover the drug. We will also continue to update our online Drug List as scheduled and provide other required information to reflect drug changes. (To learn more about changes we may make to the Drug List, see Chapter 5, Section 6 of the Evidence of Coverage.)

Changes to Prescription Drug Costs

Note: If you are in a program that helps pay for your drugs (“Extra Help”), the information about costs for Part D prescription drugs may not apply to you. We send you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug costs. If you receive “Extra


Help” and haven’t received this insert by September 30, 2019, please call customer service and ask for the “LIS Rider.” Phone numbers for customer service are in Section 7.1 of this booklet.

There are four “drug payment stages.” How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.)

The information below shows the changes for next year to the first two stages – the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages – the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the Evidence of Coverage, which is located on our website at networkhealth.com/medicare/plan-materials. You may also call customer service to ask us to mail you an Evidence of Coverage.)

Changes to the Deductible Stage

Stage 2019 (this year) 2020 (next year)

Stage 1: Yearly Deductible Stage

During this stage, you pay the full cost of your Tier 4, and Tier 5 drugs until you have reached the yearly deductible.

The deductible is $260.

During this stage, you pay $2 at a preferred pharmacy or $4 at a standard pharmacy for drugs on Tier 1, $8 at a preferred pharmacy or $14 at a standard pharmacy for drugs on Tier 2 and the full cost of drugs on Tier 3, Tier 4, and Tier 5 until you have reached the yearly deductible.

The deductible is $260.

During this stage, you pay $2 at a preferred pharmacy or $4 at a standard pharmacy for drugs on Tier 1, $8 at a preferred pharmacy or $14 at a standard pharmacy for drugs on Tier 2, $42 at a preferred pharmacy or $47 at a standard pharmacy for drugs on Tier 3 and the full cost of drugs on Tier 4 and Tier 5 until you have reached the yearly deductible.

Changes to Your Cost-sharing in the Initial Coverage Stage

To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage.



Stage 2019 (this year) 2020 (next year)

Stage 2: Initial Coverage Stage

Once you pay the yearly deductible, you move to the Initial Coverage Stage. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.

The costs in this row are for a one-month (30-day) supply when you fill your prescription at an in-network pharmacy. For information about the costs for a long-term supply or for mail-order prescriptions, look in Chapter 6, Section 5 of your Evidence of Coverage.

We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List.

Your cost for a one-month supply at an in-network pharmacy:

Tier 1 Preferred Generic Drugs:

Standard cost-sharing: You pay $4 per prescription.

Preferred cost-sharing: You pay $2 per prescription.

Tier 2 Generic Drugs:



Tier 3 Preferred Brand Drugs:

Standard cost sharing: You pay $47 per prescription.

Preferred cost sharing: You pay $42 per prescription.

Tier 4 Non-Preferred Brand Drugs:



Tier 5 Specialty Drugs:

Standard cost sharing: You pay 28% of the total cost.

Preferred cost sharing: You pay 28% of the total cost.

Once your total drug costs have reached $3,820 you will move to the next stage (the Coverage Gap Stage).

Your cost for a one-month supply at an in-network pharmacy:

Tier 1 Preferred Generic Drugs:



Tier 2 Generic Drugs:



Tier 3 Preferred Brand Drugs:



Tier 4 Non-Preferred Brand Drugs:



Tier 5 Specialty Drugs:

Standard cost sharing: You pay 28% of the total cost.

Preferred cost sharing: You pay 28% of the total cost.

Once your total drug costs have reached $4,020 you will move to the next stage (the Coverage Gap Stage).


Changes to the Coverage Gap and Catastrophic Coverage Stages

The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage Stage – are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage.

SECTION 2 Administrative Changes

Process 2019 (this year) 2020 (next year)

Drugs that are on Tier 3 will no longer require deductible be met before copayment applies.

Deductible then copayment $42 at a preferred pharmacy or $47 at a standard pharmacy

Certain Part B medications and Part B chemotherapy will require an alternative medication be used before the requested medication will be covered (Step Therapy).

No Step Therapy requirement Step Therapy requirement on certain Part B medications and Part B chemotherapy

Caregiver Support Caregiver support is not covered.

Our trained Care Managers can provide support and local resources for you as a caregiver and for your authorized representatives. Call 866-7090019 for more information.

SECTION 3 Deciding Which Plan to Choose

Section 3.1 – If you want to stay in Network PlatinumPremier Pharmacy

To stay in our plan you don’t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically stay enrolled as a member of our plan for 2020.

Section 3.2 – If you want to change plans

We hope to keep you as a member next year but if you want to change for 2020 follow these steps:


Step 1: Learn about and compare your choices

You can join a different Medicare health plan timely,

– OR– You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan. If you do not enroll in a Medicare drug plan, please see Section 2.1 regarding a potential Part D late enrollment penalty.

To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2020, call your State Health Insurance Assistance Program (see Section 5), or call Medicare (see Section 7.2).

You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to https://www.medicare.gov and click “Find health & drug plans.” Here, you can find information about costs, coverage, and quality ratings for Medicare plans.

As a reminder, Network Health Insurance Corporation offers other Medicare health plans. These other plans may differ in coverage, monthly premiums, and cost-sharing amounts.

Step 2: Change your coverage

To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from Network PlatinumPremier Pharmacy.

To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from Network PlatinumPremier Pharmacy.

To change to Original Medicare without a prescription drug plan, you must either:

o Send us a written request to disenroll. Contact customer service if you need more information on how to do this (phone numbers are in Section 7.1 of this booklet),

o – OR – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.

SECTION 4 Deadline for Changing Plans

If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2020.

Are there other times of the year to make a change?

In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get “Extra Help” paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area may be allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage.

If you enrolled in a Medicare Advantage Plan for January 1, 2020, and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or



switch to Original Medicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2020. For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage.

SECTION 5 Programs That Offer Free Counseling about Medicare

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In Wisconsin, the SHIP is called The Board on Aging and Long Term Care.

The Board on Aging and Long Term Care is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. The Board on Aging and Long Term Care counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call The Board on Aging and Long Term Care at 800-242-1060. You can learn more about The Board on Aging and Long Term Care by visiting their website (http://longtermcare.wi.gov).

SECTION 6 Programs That Help Pay for Prescription Drugs

You may qualify for help paying for prescription drugs. Below we list different kinds of help:

“Extra Help” from Medicare. People with limited incomes may qualify for “Extra Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75 percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don’t even know it. To see if you qualify, call:

o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;

o The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778 (applications); or

o Your State Medicaid Office (applications).

Help from your state’s pharmaceutical assistance program. Wisconsin has a program called Wisconsin Senior Care that helps people pay for prescription drugs based on their financial need, age, or medical condition. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Section 5 of this booklet).

Prescription Cost Sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost sharing assistance through the Wisconsin AIDS/HIV Drug Assistance Program. For information on eligibility criteria, covered drugs, or how to enroll in the program, please call 608-267-6875 or 800-991-5532.

http://longtermcare.wi.gov


SECTION 7 Questions?

Section 7.1 – Getting Help from Network PlatinumPremier Pharmacy

Questions? We’re here to help. Please call customer service at 800-378-5234. (TTY only, call 800-947-3529.) We are available for phone calls Monday through Friday, 8 a.m. to 8 p.m. Calls to these numbers are free.

Read your 2020 Evidence of Coverage (it has details about next year's benefits and costs)

This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2020. For details, look in the 2020 Evidence of Coverage for Network PlatinumPremier Pharmacy. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is located on our website at networkhealth.com/medicare/plan-materials. You may also call customer service to ask us to mail you an Evidence of Coverage.

Visit our Website

You can also visit our website at networkhealth.com/medicare/plan-materials. As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) and our list of covered drugs (Formulary/Drug List).

Section 7.2 – Getting Help from Medicare

To get information directly from Medicare:

Call 1-800-MEDICARE (1-800-633-4227)

You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Visit the Medicare Website

You can visit the Medicare website (https://www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to https://www.medicare.gov and click on “Find health & drug plans.”)

Read Medicare & You 2020

You can read Medicare & You 2020 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don’t have a copy of this booklet, you can get it at the Medicare website (https://www.medicare.gov) or by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.






REQUIRED INFORMATION - Nondiscrimination

Network Health complies with applicable Federal civil rights laws, conscience and anti-discrimination laws and prohibiting exclusion, adverse treatment, coercion or other discrimination against individuals or entities on the basis of their religious beliefs or moral convictions and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Network Health does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. You may have the right under federal law to decline to undergo certain health care‐related treatments, research, or services that violate your conscience, religious beliefs, or moral convictions.

Network Health:

Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other

formats) Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters o Information written in other languages

If you need these services, contact Network Health’s discrimination complaints coordinator at 800-378-5234 (TTY 800-947-3529).

If you believe that Network Health has failed to provide these services, has failed to accommodate your conscientious, religious or moral objection or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with Network Health’s discrimination complaints coordinator, 1570 Midway Place, Menasha, WI 54952, phone number 800-378-5234, TTY 800-947-3529, Fax 920-720-1907, [email protected]. You can file a grievance in person orby mail, fax, or email. If you need help filing a grievance, Network Health’s discrimination complaints coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Multi-language Interpreter Services

If you, or someone you’re helping, has questions about Network Health, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 800-378-5234 (TTY 800-947-3529).

Albanian: Nëse ju, ose dikush që po ndihmoni, ka pyetje për Network Health, keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin 800-378-5234 (TTY 800-947-3529).

Arabic:

Health Network ، باللغة والمعلومات مساعدةال على الحصول في حقال لديك حول أسئلة مساعدة، نتك شخص لدى أو لديك كان إذا.(TTY 800-947-3529) 5234-378-800 باستدعاء قم وري،ف مترجم مع للتحدث .فةكلت أي وند بك الخاصة

2525-01-0719 Medicare

http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

mailto:[email protected]

Chinese:如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱 Network Health方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話 [在此插入數字 800-378-5234 (TTY 800-947-3529).

French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Network Health, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 800-378-5234 (TTY 800-947-3529).

German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Network Health haben, haben Sie das

ຈ່

Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 800-378-5234 (TTY 800-947-3529) an.

Hindi: यिद आप, या िकसी को आप की मदद कर रहे , के बारे सवाल है Network Health, आपमɅ कोई भी कीमत पर अपनी भाषा मɅ मदद और जानकारी प्राÜत करने का अिधकार है। एक दु ेभािषया किलए बात करने िलए, 800-378-5234 (TTY 800-947-3529) कहते हɇ।.

हɇ

Hmong: Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Network Health, koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 800-378-5234 (TTY 800-947-3529).

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Network Health 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 800-378-5234 (TTY 800-947-3529). 로 전화하십시오.

ມູ Laotian: ຖ້ າທານ, ືຫ ນທ ານກາລງຊວຍເຫື ອ, ມຄາຖາມກຽວກັ ບ Network Health, ທານມ ສດທ່ ຼ ່ ໍ ັ ່ ຼ ໍ ່ ່ ິ ່ທ່

ໍ ່ຈະໄດ ບການຊວຍເຫອແລະຂ້ ນຂາວສານທເປນພາສາຂອງທານບມ ຄາໃຊ າຍ. ການໂອ ມກັ ບນາຍພາສາ, ໃຫ້ ໂທຫາ 800-378-5234 (TTY 800-947-3529). ້ ່ ື ຼ ່ ່ ັ ່ ໍ ່ ້

ຄົ

Pennsylvania Dutch: Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut

के

Network Health, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 800-378-5234 (TTY 800-947-3529) uffrufe.

ລົ ຮັ ້

Polish: Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie Network Health, masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 800-378-5234 (TTY 800-947-3529).

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Network Health, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 800-378-5234 (TTY 800-947-3529).

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Network Health, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 800-378-5234 (TTY 800-947-3529).

Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Network Health, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 800-378-5234 (TTY 800-947-3529).

Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Network Health, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 800-378-5234 (TTY 800-947-3529).

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